<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:panel>
    <form wicket:id="form">
        <div class="modal-header">
            <button type="button" class="close" data-dismiss="modal">&times;</button>
            <h3>Verwerken inzage/overdracht persoonsgegevens</h3>
        </div>
        <div class="modal-body form-horizontal">
            <fieldset class="hero-unit">
                <p>Om aanvraag inzage/overdracht persoonsgegevens te kunnen verwerken moet eerst het antwoordformulier <strong>MET een handtekening van
                    de cli&euml;nt</strong> worden geupload.</p>
            </fieldset>
            <div class="control-group span7">
                <div class="row">
                    <div class="control-group">
                        <label class="control-label">Verstuurde brieven</label>
                        <div class="controls">
                            <ul class="lijst" wicket:id="brievenLijst">
                                <li><label style="font-weight: bold;" wicket:id="brief"></label></li>
                            </ul>
                        </div>
                    </div>
                </div>
                <div class="row" wicket:id="uploadContainer">
                    <div class="control-group">
                        <label class="control-label">Bestand selecteren</label>
                        <div class="controls">
                            <input class="control-input" type="file" wicket:id="fileUpload">
                        </div>
                    </div>
                </div>
                <div class="row">
                    <div class="control-group">
                        <label class="control-label">Keuzes <i class="icon-asterisk icon-purple"></i></label>
                        <div class="controls">
                            <div class="span 4">
                                <label class="checkbox">
                                    <input type="checkbox" wicket:id="bkGegevens">
                                    Borstkanker (persoonsgegevens)
                                </label>
                                <label class="checkbox">
                                    <input type="checkbox" wicket:id="bkBeelden">
                                    Borstkanker (beelden)
                                </label>
                                <label class="checkbox">
                                    <input type="checkbox" wicket:id="bmhkGegevens">
                                    Baarmoederhalskanker
                                </label>
                                <label class="checkbox">
                                    <input type="checkbox" wicket:id="dkGegevens">
                                    Darmkanker
                                </label>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
            <div wicket:id="documentVervangen"/>
        </div>
        <div class="modal-footer">
            <a href="javascript:void(0);" class="btn left" wicket:id="downloadFormulier"><i class="icon-download"></i>Aanvraagformulier</a>
            <a class="btn left" wicket:id="geenHandtekening">Geen handtekening?</a>
            <a class="btn left" wicket:id="vervangen">Vervangen document </a>
            <a class="btn" wicket:id="afronden">Afronden</a>
            <a href="javascript:void(0);" wicket:id="download" class="btn"><i class="icon-mimetype-csv"></i><span>Download</span></a>
            <a class="btn" data-dismiss="modal">Annuleren</a>
            <a href="javascript:void(0);" class="btn btn-primary" wicket:id="opslaan">Opslaan</a>
        </div>
    </form>
    <div wicket:id="dialog"></div>
</wicket:panel>
</html>
